Paraphilic Disorders: Characteristics, Types and Treatment
Paraphilic disorders go beyond paraphilias (fantasies and sexual arousal to atypical stimuli or situations), because they involve suffering for the person with the disorder, or a deterioration in their life. We’ll tell you about up to 8 types of paraphilic disorders.
In all of them, the symptoms must appear for at least 6 months. Get to know here their characteristics, prevalence, manifestations and how they can be treated through pharmacology and psychotherapy.
Paraphilic disorders: characteristics
Paraphilic disorders are defined as “recurrent and intense fantasies of sexual arousal, as well as distressing or disabling sexual drives or behaviors involving atypical stimuli or situations”.
We’re generally speaking here of inanimate objects, children or adults without their consent, the suffering or humiliation of the partner (or oneself), with the probability of causing harm, etc.
In DSM-5 (Diagnostic and Statistical Manual of Mental Disorders), paraphilic disorders are categorized as such. On the other hand, in the ICD-10 (International Classification of Diseases), paraphilias are called “disorders of sexual orientation”.
Paraphilia vs. paraphilic disorder
To speak of a paraphilic disorder and not just a paraphilia, there must be suffering or harm for the individual, or that the satisfaction of one’s own paraphilia implies harm or risk of harm to others.
That is why it would be good to differentiate paraphilic disorders (with suffering or interference in the life of the individual) from paraphilias (without suffering or interference).
Course and development of paraphilic disorders
Paraphilic disorders generally begin during puberty. However, fetishes can develop before adolescence.
Once the disorder is established, it usually runs a continuing course (such as fetish disorder), fluctuating in the frequency and intensity of the unrestrained behaviors or desires.
8 types of paraphilic disorders
In DSM-5 we find up to 8 types of paraphilic disorders. Let’s see the characteristics and prevalence of each of them.
1. Exhibitionism disorder
Exhibitionism disorder is a type of paraphilic disorder in which, over a period of at least 6 months, recurrent and intense sexual arousal occurs due to the exposure of one’s genitalia to a stranger. This excitement manifests itself from fantasies, impulses or certain behaviors.
In order to be diagnosed with this disorder, the individual must have fulfilled these irrepressible sexual desires with a person who has not consented.
It may be the case that these sexual desires or fantasies cause significant distress or impairment (a sufficient condition to diagnose exhibitionism disorder, even if the former doesn’t apply).
Exhibitionism disorder is called exhibitionism in ICD-10, with criteria similar to those of DSM-5. However, it adds, among its criteria, that there’s no intention of sexual contact with the witness.
Specifications of the disorder
On the other hand, the DSM-5 indicates that one of the following conditions must be specified: if the person is excited by the exposure of the genitals to prepubertal children, to physically mature individuals or both.
It must be specified whether the behavior occurs in a controlled environment, and whether or not it is in full remission.
Prevalence
According to DSM-5, the prevalence of exhibitionism disorder is unknown. However, based on the cases of exhibitionism observed in non-clinical samples or the general population, there’s talk of a maximum prevalence of the disorder in 2-4% of men.
In women, this prevalence is even more unknown, but it is believed to be much lower than in men.
2. Fetish disorder
Another paraphilic disorder is fetishism disorder. It implies intense and recurrent sexual arousal derived from the use of inanimate objects (for example, heels, dresses…) or a great specific interest on the part (s) of the non-genital body (for example, feet, hands, back…).
All these fantasies, as occurs in other paraphilic disorders, generate discomfort or impairment in daily functioning. The DSM-5 indicates that in the fetishistic disorder it must be specified if the excitement occurs:
- With body part(s).
- With inanimate object(s).
In ICD-10, as with exhibitionism disorder, this disorder is termed simply fetishism. The criteria are similar, although in the case of the ICD-10 it speaks of sexual arousal from “inert objects”, this being the most important source of sexual stimulation for the person. Either that, or it must be essential for a satisfactory sexual response.
Prevalence
The prevalence of fetishism disorder is unknown, but we do know that cases have been described almost exclusively in men in the clinical population.
3. Frotteurism disorder
Another paraphilic disorder is frotteurism disorder. It implies the existence of intense and recurrent sexual arousal, in this case derived from touching or friction against a person without their consent.
These touches are performed in small spaces with many people and where you can go “unnoticed”, such as in the subway. Such arousal, as in previous paraphilic disorders, is manifested by fantasies, irrepressible desires, or behaviors. These symptoms appear for at least 6 months.
In addition, one of the following conditions must be met: either the person has fulfilled these wishes with a person who has not given their consent, or the fantasies cause discomfort or impairment in daily functioning.
Prevalence
In terms of its prevalence, acts of friction (including unwanted touching and friction of a sexual nature with other individuals) can occur in up to 30% of adult men in the general population.
According to data from the same manual, about 10-14% of adult males visited in outpatient clinics for paraphilic disorders or hypersexuality have a presentation that meets the diagnostic criteria for this disorder.
4. Pedophilia disorder
Pedophilia or pedophilia disorder involves intense and recurring sexual arousal derived from fantasies, irrepressible sexual desires, or behaviors that involve sexual activity with one or more prepubertal children (usually under 13 years of age).
To speak of pedophilia, it is necessary that the person with pedophilia has fulfilled those wishes with the minor, or that said fantasies cause significant discomfort or interpersonal problems. On the other hand, the person with pedophilia must be at least 16 years old, and must be at least 5 years older than the child.
Individuals in their late teens who have a continuous sexual relationship with another 12- or 13-year-old should not be included in pedophilia cases.
Pedophilia specifications
Among the specifications of pedophilia, the following must be carried out: specify whether it is pedophilia of an exclusive type (exclusive attraction to children) or non-exclusive type (attraction also to adults).
It’s also necessary to specify if the sexual attraction is for the male sex, for females, or for both. Finally, it will be indicated whether pedophilia appears limited to incest or not.
Prevalence
The prevalence of pedophilia is unknown in the population, although the maximum prevalence of the disorder in the male population is approximately 3-5%. In women, the prevalence is even more uncertain, although it is probably much lower than in the case of men.
5. Sexual masochism disorder
It involves intense and recurring sexual arousal derived from being humiliated, beaten, tied up, or subjected to suffering in any other way. These symptoms last, at least, 6 months, and cause discomfort in the subject or interference in their day-to-day life.
It can be specified whether or not it appears with asphyxiophilia (when the person seeks to achieve sexual arousal through restriction of breathing). In ICD-10, this disorder is called sadomasochism.
Prevalence
The prevalence of sexual masochism disorder is unknown. However, according to DSM-5 data, in Australia, for example, it has been estimated that 2.2% of men and 1.3% of women have practiced acts of servitude and punishment, sadomasochism or dominance and submission over the past 12 months.
6. Sexual sadism disorder
In this case, we’re speaking of a sexual arousal derived from the physical or psychological suffering of another person. In addition, the person hasn’t given their consent (or the symptoms cause discomfort or deterioration in the person suffering from the disorder).
Regarding its prevalence, it’s estimated that it ranges between 2 and 30% in the population.
7. Cross-dressing disorder
Cross-dressing implies a recurrent and intense sexual arousal from the use of clothing of the opposite sex. This manifests itself through fantasies, impulses or behaviors that cause discomfort or deterioration.
At the prevalence level, it’s a rare disorder in men and extremely rare in women. Less than 3% of men report having been sexually aroused by wearing women’s outfits.
8. Voyeurism
This involves arousal derived from the observation of an unsuspecting person who is undressing or engaging in sexual activity. The individual must be at least 18 years of age.
In ICD-10 this disorder is called scoptophilia. The highest possible lifetime prevalence of the disorder is estimated to be 12% in men and 4% in women.
Treatment
Regarding the treatment of paraphilic disorders, it must be adapted to each individual and specific disorder. A combination of psychopharmacological, psychological and surgical treatments is usually used in some cases. Here we’ll talk about the first two.
Pharmacotherapy
Regarding drug treatment, it’s possible to intervene in sexual desire by manipulating its hormonal substrate. Thus, the hormonal treatment of paraphilias includes the use of medroxyprogesterone acetate (AMP) and cyproterone acetate (ACP).
Estrogens had been used for a long time. The use of tranquilizers has also been proposed. Haloperidol has been widely used, with the thinking being that it’s the most specific when it comes to reducing libido.
Psychological treatment
For the treatment of paraphilic disorders, authors such as Marshall et al. (1991) have postulated their theories. They showed that programs that include cognitive changes and improvement of interpersonal relationships are more effective than those that only focus on modifying sexual preferences.
In psychological treatment, it’s recommended, whenever possible, to start with constructive and positive approaches for the development of more adaptive ways of achieving gratification and not only to eliminate the existing problem. The areas that the interventions focus on, at a psychological level, are the following:
- Development of positive linkers
- Deserotization of paraphilic stimuli
Paraphilias are much more common in the population than paraphilic disorders. In the first case, we speak of behavior patterns where the predominant source of sexual pleasure is found in atypical or infrequent activities, stimuli or situations.
On the other hand, in paraphilic disorders, the symptom is the same but we add to this the suffering that the person experiences. In any case, if you think you may have a paraphilic disorder, we recommend that you seek professional help as soon as possible.
- American Psychiatric Association –APA- (2014). DSM-5. Manual diagnóstico y estadístico de los trastornos mentales. Madrid: Panamericana.
- Belloch, A., Sandín, B. y Ramos, F. (2010). Manual de Psicopatología. Volumen I y II. Madrid: McGraw-Hill.
- Caballo (2002). Manual para el tratamiento cognitivo-conductual de los trastornos psicológicos. Vol. 1 y 2. Madrid. Siglo XXI.
- Chalkley, A. J., y Powell, G. E. (1983). The clinical description of forty-eight cases of sexual fetishism. En: British Journal of Psychiatry, 142: 292–295.
- OMS: CIE-10. (1992). Trastornos Mentales y del Comportamiento. Décima Revisión de la Clasificación Internacional de las Enfermedades. Descripciones Clínicas y pautas para el diagnóstico. Organización Mundial de la Salud, Ginebra.
- Salazar, M., Peralta, C., & Pastor, F.J. (2009). Tratado de Psicofarmacologia (2ª Ed.). Madrid: Editorial Panamericana.
- Santos, J.L. ; García, L.I. ; Calderón, M.A. ; Sanz, L.J.; de los Ríos, P.; Izquierdo, S.; Román, P.; Hernangómez, L.; Navas, E.; Ladrón, A y Álvarez-Cienfuegos, L. (2012). Psicología Clínica. Manual CEDE de Preparación PIR, 02. CEDE. Madrid.